Conclusions and recommendations |
1. Insufficient progress has been made in
achieving the Department's plans in Building a Safer NHS for Patients. In
particular the National Patient Safety Agency was very late in
delivering the National Reporting and Learning System and has
provided only limited feedback to NHS trusts on solutions to reduce
serious incidents. The National Patient Safety Agency has also
failed to evaluate and promulgate solutions that have been developed
at trust level. As a result the Agency has yet to demonstrate
good value for money.
2. Trusts estimated that on average around
22% of incidents and 39% of near misses go un-reported, and that
medication errors and incidents leading to serious harm are the
least likely to be reported. The National
Patient Safety Agency should compare its own data with the incident
reporting data collected by the National Audit Office. It should
bring together trusts with low levels of reporting and those that
have achieved high reporting rates to help improve incident and
near miss reporting. The Healthcare Commission should evaluate
compliance with reporting requirements as part of its performance
3. The lack of accurate information on serious
incidents and deaths makes it difficult for the NHS to evaluate
risk or get a grip on reducing high risk incidents.
The National Patient Safety Agency needs to obtain a more precise
understanding of the extent and causes of death and serious harm.
To do so, it needs to collect information on the contributory
factors and develop a more targeted, risk based, approach to solutions
aimed at reducing such incidents.
4. Doctors are less likely to report an incident
than other staff groups. The National
Patient Safety Agency has run a national initiative to encourage
reporting by junior doctors, and should promulgate the lessons
from this initiative across the NHS. Trusts should evaluate their
own levels of under-reporting and target specific training and
feedback at those groups of staff that are less likely to report.
5. Although most trusts stated their safety
culture had become more open and fair, less than half of trusts
had conducted a formal assessment of progress.
In 2004, 23% of trusts felt they had an open and fair culture
throughout their organisation, and another 72% felt their safety
culture was predominantly open and fair. By 2005, the percentage
of trusts rating themselves as having an open and fair culture
throughout had increased to 32%, while those judging their culture
only predominantly open and fair had reduced to 65%. All trusts
should assess their safety culture using one of the established
tools, such as those listed in the National Patient Safety Agency's
guidance Seven steps to patient safety, and implement action
plans to address the issues identified.
6. Disciplinary action may be an appropriate
response when patient safety is at risk, but the perception amongst
nursing and other non-medical staff is that they risk suspicion
if they report a serious incident. Our
predecessors' Report on the management of suspensions (HC 296,
2003-04) identified an over-reliance on disciplinary measures.
The Department still does not monitor the nature and length of
non-medical staff suspensions, or the management action taken
on them. The Department and NHS trusts should act on the previous
Committee's recommendation to extend the role of the National
Clinical Assessment Service to cover all staff.
7. Patient safety alerts and other solutions
are not always complied with though trusts self-certify that they
have implemented them. For example, the
Chief Medical Officer's 2004 report found that 50 days after the
deadline for implementing a safety alert on oral methotrexate,
only 54% of organisations had completed the actions required to
reduce harm. In evaluating trusts' self assessments the Healthcare
Commission with the Standards for Better Health should require
trusts to provide evidence on the extent of compliance. During
inspection visits they should evaluate and report on how well
alerts and other solutions have been put into practice.
8. Only 24% of trusts routinely inform patients
involved in a reported incident and 6% do not involve patients
at all. Only 69% of trusts had criteria
for staff to follow. Using the National Patient Safety Agency
guidance on Being Open, all trusts should as a matter of
course inform patients and their carers if they have been involved
in an incident, even if they suffered no harm. Patients and carers
should also be consulted to help identify solutions.
9. It took until July 2005, for the National
Patient Safety Agency to produce its first feedback report to
trusts on the number of incidents reported and some specific solutions
to particular types of incidents. The
Department should hold the National Patient Safety Agency to their
commitment to produce feedback reports at least quarterly. These
feedback reports should include illustrative business cases to
demonstrate the cost-effectiveness of implementing solutions to
10. The National Reporting and Learning System
has not, as hoped, helped simplify the complexity for trusts in
reporting incidents. The Department, NHS
Connecting for Health and the National Patient Safety Agency should
agree a plan and timetable for rationalising the reporting routes
so that within the next two to three years trusts need make only
one report of an incident, which is then automatically distributed
to the relevant organisation.
11. To choose between hospitals under the
NHS Choice agenda, patients will need access to robust information
on patient safety, including comparable information from independent
sector providers. The National Patient
Safety Agency anonymises the data it collects and was not tooled
up to provide comparable information. The Department needs to
agree whether and how such information will now be provided and
who will be responsible for publishing the data.
12. The taxonomy of the National Reporting
and Learning System differs from many local trust descriptions
and classifications of incidents and also from taxonomies used
by other countries. The World Health Organisation
is developing an international taxonomy. The National Patient
Safety Agency should either adopt this taxonomy or align its taxonomy
fully to it, though with scope to meet additional requirements
that the Agency may deem necessary.